Resection of Dieulafoy's lesion by a combined endoscopic and laparoscopic approach.

Dieulafoy's lesion is a vascular malformation, usually of the stomach but occasionally of the small or large bowel. It is an uncommon but clinically significant source of massive upper gastrointestinal (GI) hemorrhage. The lesion is generally located high on the lesser curvature in the proximal stomach. Although most bleeding can be controlled endoscopically, surgery is occasionally required. The traditional approach was open laparotomy, gastrotomy to localize the lesion, followed by partial gastrectomy or wedge resection. The following case report describes and illustrates a method of intraluminal endoscopic localization of the lesion followed by laparoscopic gastric wedge resection using a 3-port technique.

Iatrogenic "respiratory acidosis" during laparoscopic preperitoneal hernia repair.

This is the first report, to our knowledge, of a case of massive subcutaneous emphysema during totally preperitoneal laparoscopic hernia repair causing a "respiratory acidosis" with a systemic pH 7.20 and a pCO2 of 64 and PO2 of 84. The acidosis was corrected by increased mechanical ventilation. It appears that because of its lack of defined borders, the preperitoneal space is particularly vulnerable to the formation of massive subcutaneous emphysema. Thus, there is a large potential surface area for CO2 absorption. The complication may be prevented by increased attention to the length of fascial incisions, inflation of balloon expanding devices, and securing gripping devices in the port sites.

The value of laser Doppler velocimetry and transcutaneous oxygen tension determination in predicting healing of ischemic forefoot ulcerations and amputations in diabetic and nondiabetic patients.

The ability to predict successful healing of ulcerations and amputations of the ischemic forefoot continues to be a major clinical challenge, particularly in diabetic patients whose systolic Doppler ankle pressures are often artifactually elevated. We have used the techniques of laser Doppler velocimetry (LD) and transcutaneous oxygen tension monitoring (tcPO2) to quantitatively measure skin blood flow in the distal foot. Fifty-nine limbs were studied (48 patients), of which 37 (63%) were in diabetic and 22 (37%) in nondiabetic patients. All patients were admitted with ischemic ulcerations or gangrenous changes of the forefoot or digit. Twenty transmetatarsal or digital amputations were performed; the remainder of the lesions were débrided and allowed to heal by secondary intention or were covered by a skin graft. Before operation, the systolic pressure (expressed in millimeters of mercury, mean +/- SEM) was measured by Doppler technique at the ankle, and the ankle/arm index calculated (n = 59 limbs). The tcPO2 (also expressed in millimeters of mercury, mean +/- SEM) was measured from the dorsal foot (n = 56). The baseline skin blood flow velocity (SBFV) and pulse wave amplitude (PWA) were measured with the LD (expressed in millivolts, mean +/- SEM) on the plantar aspect of the foot (n = 53 limbs). Criteria for successful healing included a tcPO2 of more than 10 mm Hg, the combination of an LD-SBFV of more than 40 mV and an LD-PWA of more than 4 mV, and an ankle systolic pressure of more than 30 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of revascularization and amputation in severe lower extremity ischemia: a five-year clinical experience.

Aggressive revascularization of the ischemic lower extremity in atherosclerotic occlusive disease by femoropopliteal (FP) and femorotibial (FT) bypass or profundaplasty (P), as indicated, has been advocated by some authors for all patients. Others have recommended primary amputation, particularly for tibial occlusive disease. To clarify this clinical dilemma, we reviewed the results of 547 procedures performed during the last 5 years: revascularization in 375 (69%) instances and below-knee amputation (BKA) in 172 (31%) cases. Bypass procedures were used in 246 cases: FP in 155 (64%) and FT in 91 (37%). Reversed autogenous saphenous vein (ASV) was used preferentially in 125 (51%) cases, whereas polytetrafluoroethylene (PTFE) was used in 121 (49%) cases. P was performed in 129 instances accompanied by inflow procedures in 92 (71%) of these cases. Cumulative limb salvage (LS) exceeded bypass patency in all categories and resulted in 2- and 5-year LS rates of 83% and 81% for FP with the use of ASV and 52% and 35% for PTFE. The LS rate for FT was 53% and 47%, respectively, for ASV and 20% and 15% for PTFE. Rest pain was successfully relieved by P in 99 cases (77%), whereas healing occurred in only 51% of cases with tissue loss. The perioperative mortality rate for revascularization was 3%; 42% of the group died during follow-up, death usually resulting from complications of atherosclerosis. Of the 172 BKAs, primary healing occurred in 80%, but the perioperative mortality rate was 13%. FP and FT bypasses are preferred procedures if ASV is available, whereas use of PTFE should be limited to FP bypasses only. Rest pain is relieved by P but tissue loss should prompt consideration for bypass. BKA should be considered in cases of severe tibial disease only in the absence of a suitable ASV, as the perioperative mortality rate is high and ultimate rehabilitation (64%) is limited.

Asymptomatic carotid disease.

The advent of noninvasive screening tests has allowed the identification of an increasing number of patients with asymptomatic carotid stenoses. The management of these patients must be individualized, as the preferred method of therapy has not been established. Such a solution ultimately requires a prospective randomized trial to define the natural history of these lesions and to clearly establish if surgical therapy has a role. Currently, there is a Veterans Administration Cooperative Study underway which will attempt to fill the existing information gap. Specifically being examined is the relationship between subsequent cerebrovascular symptoms and the degree of stenosis, progression of stenosis, contralateral disease and non-carotid operation. This study will not be completed for five years, so that other, current guidelines must be sought. It is essential that any surgeon considering prophylactic carotid endarterectomy demonstrate combined morbidity and mortality figures of less than 3 per cent. The patients being considered must also be an acceptable cardiac risk, as myocardial infarction represents the most common postoperative complication. Until prospective data is available, with a detailed analysis of the degree of stenosis, presence of ulceration and ultimate clinical course, the surgeon undertaking prophylactic endarterectomy must carefully screen his patients and concentrate on groups at high risk. This is especially important as more data on the significant incidence (10 to 15 per cent) of carotid restenosis becomes available. The results of three studies (34, 36, 69) suggest that those patients with hemodynamically significant stenoses, identified noninvasively by OPG techniques, are at a greater risk for cerebral ischemic events than those patients without significant stenoses. In addition, an observed incidence of stroke of 17.5 per cent and an indicence of TIAs of 33 per cent in patients with disease progression demonstrated by OPG-K/CPA. The work of another researcher (71) suggests that patients with carotid stenoses can be observed until symptoms develop or until the stenosis progresses to greater than 80 per cent.(ABSTRACT TRUNCATED AT 400 WORDS)

The assessment of skin blood flow in peripheral vascular disease by laser Doppler velocimetry.

The helium-neon laser Doppler (LD) is designed to measure skin blood flow velocity (SBFV). Flow velocity and pulse wave amplitude are expressed in millivolts (mv) relative to a zero-flow reference. The authors have reviewed their initial experience in ten persons (20 limbs) without peripheral vascular disease (PVD, group I) and nine patients (12 limbs) with severe PVD (group II). The finger, palm, great toe, and forehead had a significantly (P less than 0.05) greater flow velocity than the plantar and dorsal foot, distal and proximal leg, thigh, chest, arm, and forearm. Baseline and hyperemic SBFV, measured at the great toe, were compared in groups I and II. In group I, the baseline SBFV (mv, mean +/- standard error of the mean (SEM] in the great toe was 197 +/- 38 compared with 67 +/- 12 in group-II patients (P less than 0.05). The pulse wave amplitude (mv, mean +/- SEM) was 77 +/- 14 in group I and 5.4 +/- 1.1 in group II (P less than 0.05). The time to maximal hyperemic response (seconds, mean +/- SEM) in group I was 18 +/- 1.5 compared with 150 +/- 14 in group II (P less than 0.05). LD is a sensitive indicator of changes in SBFV, allowing differentiation between normal persons and patients with PVD. The LD tracing in patients with PVD is characterized by a baseline SBFV that is significantly less than normal and also by the attenuation or absence of pulse waves. The diagnostic accuracy is enhanced by the use of reactive hyperemia.

Regional vs systemic effect of cis-dichlorodiammine platinum (II) on squamous cell carcinoma in rats.

Utilizing a model that compares the effects of chemotherapeutic agents given regionally vs systemically in the same animal, the effects of cis-dichlorodiammine platinum (II) (cis-platinum) were evaluated. Squamous cell carcinoma was implanted at the bases of both ears of Fisher-344 rats. By retrograde cannulation of a branch of the external carotid artery, tumors on the right were treated by intra-arterial infusions of varying doses of cis-platinum while tumors on the left were treated only after systemic circulation of the same drug. The investigators found that cisplatinum is effective in decreasing the rate of tumor growth compared to control animals treated with saline; however, they found no difference in the rate of growth between tumors treated regionally vs systemically and therefore no advantage in the intra-arterial administration of the drug at the doses and rates of infusion tested.

Effect of age and splenectomy in murine endotoxemia.

The protective role of the spleen in gram-positive infections, particularly in infancy and childhood, is well established. Since it is not known whether the spleen is protective in gram-negative sepsis, particularly in elderly individuals as compared to young subjects, the following study was undertaken. Splenectomized and nonsplenectomized Swiss Webster mice, 3 months old (young), or 12 months old (elderly) were utilized. Splenectomy was performed 4 weeks prior to administration of E coli endotoxin. Mortality in elderly nonsplenectomized mice was significantly greater than that of young nonsplenectomized mice. Prior splenectomy significantly increased the mortality in young mice at 48 h, whereas the mortality of E coli endotoxemia (ECE) in elderly mice was not altered by prior splenectomy. The spleen, therefore, appears to have a protective role for young mice but does not protect elderly mice with ECE. It is postulated that this loss of splenic protection reflects deteriorating splenic function with age.

Penetrating injuries to the colon.

In planning the management of a colonic injury, several factors must be taken into account, including the age of the patient, the cause of the wound, the time lapse from injury to operation, area and the type of wound, the amount of fecal soilage, and the number and extent of associated injuries. For extensive wounds with associated injuries, fecal contamination of the abdomen, or delay from injury to treatment, a two-stage procedure is preferred. Primary closure or primary resection is the preferred treatment for right colon injuries, depending on the severity of the injury. Resection and anastomosis should not be performed in the left colon without a diverting colostomy. Exteriorization is a satisfactory procedure for major colon injury; however, exteriorization and repair have a higher associated complication rate than exteriorization alone. Primary repair is a safe and acceptable procedure, irrespective of the site of injury. Indications for primary repair may, in the future, be expanded to include those wounds presently being treated by exteriorization.